PHYSICAL ASSESSMENT

General Appearance E.S. was awake lying in bed and wearing a white shirt and shorts with IVF of PNSS 1L
KVO attached to the right cephalic vein infusing well. He was skinny and seemed to be exhausted. He appeared restless and irritable during the interview.

Cephalocaudal Assessment A. Vital Signs

Date taken: January 29, 2013 Temperature: 37.5 C/ax Pulse rate: 104 bpm Respiration: 45bpm Date taken: February 4, 2013 Temperature: 38 C/ax Pulse rate: 140 bpm Respiration: 62 bpm

B. Skin Fair in complexion. Dry and Warm to touch. Has poor skin turgor Presence of scar Slight yellowish discoloration noted

C. Hair and Scalp

Hair: Black in color No presence of lice Smooth texture Scalp: Lighter in color No scars noted No presence of dandruff

No lesions noted No tenderness and masses on palpation

D. Nails
Poor capillary refill No clubbing noted Uncut nails Nail bed is slightly pink

E. Head and Face

Head: Normocephalic and symmetrical to his body No tenderness upon palpation No lesions noted Face: Face is symmetrical in shape No tenderness noted No scars noted No involuntary movements noted Brown complexion

F. Eyes
Sunken eyeballs Icteric eyes Brown pupils PERRLA

G. Ears
Presence of ear wax No lesions noted Upper connection of the ear lobe is parallel with the outer canthus

H. Nose
Mucus membranes are pink Both nares are patent Presence of white discharge

I. Mouth & Throat

Lips: Lips are cracked and dry No pain felt

No tenderness noted on palpation Gums: Presence of bleeding Teeth: Yellowish in color Both lower and upper teeth shows presence of cavities Bad oral hygiene Tongue: Pinkish in color Presence of cheesy patches covering the surface No lesions noted Throat: No lesions noted No presence of sore throat

J. Neck
No visible masses or lumps Presence of carotid pulse Thyroid is smooth Trachea in midline

K. Lungs and Chest

Lungs: Chest expansion symmetric and equal bilaterally Wheezing sound heard in right lung suprasternal retraction noted Chest: patient complained of chest pain No lumps noted No swelling noted

L. Abdomen
Tenderness upon palpation pain on the RUQ Bowel sounds are present has poor appetite

M. Heart
Heart murmur is heard

N. Musculoskeletal
No joint pain felt by the patient No muscle pain felt by the patient No swelling noted

O. Genitalia
Refused to be examined Able to urinate 2 times a day

P. Anus/Rectum
Refused to be examined Able to defecate 3 times a day